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He stated that he had been in the service eighteen years; had served in Cuba during the Santiago campaign, and had had some rheumatism after he returned; afterward served in the Philippines from the 10th of May to the 31st of December, 1899, and from June to December was on sick report with rheumatism; was then invalided home and spent a month in the General Hospital at Presidio, California, going thence to the hospital at Hot Springs, Arkansas, where he remained until June 1, 1900. After leaving the hospital he was well until September 29, 1902, when he entered the hospital at Fort Ringgold for fever and rheumatism, and remained there until his transfer in December. So you see that from June, 1899, to June, 1900, one year, he was continually on sick report for rheumatism and fever of which we have no record; he was probably suffering from Malta fever at that time.

He next appeared sick in September, 1902, and had a practically continuous fever until January 3, 1903.

I will now read you his history as received from Fort Ringgold: "Sergeant Frank J. Reiner, Co. E, 4th Infantry, was admitted to hospital September 29, 1902, after some time of treatment in quarters for what was believed to be a return of malarial fever. His history shows that he had fever in Cuba in 1898 and a return of the disease in the Philippine Islands, and was sent to the United States as a patient-from the Presidio he was sent to Hot Springs, Arkansas, and was treated in the Army and Navy General Hospital for 'rheumatism.' The present attack has been slow in its approach.

"The first admission to sick report was August 11, 1902; then again sick in quarters August 23rd to August 25th on account of sciatic neuralgia. The symptoms of greatest severity shown during the course of the disease have been constant pain upon moving the neck and upper dorsal region, painful to the touch or least pressure made upon the skin covering the spinous processes; pain, especially in the sciatic nerve, right side, pain in the region about the hip joint, at times in both shoulders; with this there has been a growing weakness in the lumbar and gluteal regions that has made walking

difficult, and painful points, not in the sciatic nerves as expected, but for the most part in the nerves sent to supply the hip joints and the gluteal muscles.

"Malarial cachexia has followed this irregular, continued fever. Anæmia is present, yet the fever had scarcely disturbed his appetite; the bowels have been regular, and sleep disturbed only as in cases of chronic rheumatism.

"The pain and inability to use the hip muscles in walking is believed to be the result of malarial neuritis.

"All symptoms were improving at the time of his leaving the post."

The charts which I pass around will give you a fairly good idea of the course of the fever.


DR. H. W. CROUSE, Victoria: One thing I should like to know is something about the treatment. Did you use quinine in any form?

MAJOR CHARLES F. MASON, U. S. A.: In the first case named, in which the diagnosis of Malta fever was made and the malarial organism was not found, I tried quinine sulphate, which had no effect; then I tried potassium iodide, and that had no effect, and finally I gave him a tonic of iron, quinine and strychnine, together with laxatives to keep his bowels open; on that he improved. I treated the case about six or eight weeks. DR. H. A. WEST, Galveston: Did you cure him or did he get well? MAJOR CHARLES F. MASON, U. S. A.: He got well; has never been sick since, and is now in service.

DR. H. A. WEST: Since hearing the paper of Dr. Mason on Malta fever, the idea has occurred to me of the possibility of the more frequent occurrence of such cases in Texas, which are unrecognized-for example, some of those cases diagnosticated as chronic malarial fever, which failed to yield to thorough cinchonism, may belong to the category of Malta fever. We should certainly be on the lookout for such cases.

DR. JOHN T. MOORE, Galveston: I have been noting with great interest that a number of diseases that we supposed did not exist in this country were here, and as our knowledge of them increases they become more numerous. The discovery of uncinaria is a striking example. Now, Dr. Mason comes forward with a case of Malta fever. I think we have a case

in the wards of the Sealy Hospital. I am very sure, since hearing this paper, it is a case of Malta fever. The man has been the rounds from Cuba to Porto Rico, and then from Porto Rico to San Francisco, across to the Philippines, and from the Philippines to China, then to Japan, and thence back to San Francisco. A diagnosis has been made of neuralgia, rheumatism, chronic malarial fever. The joints of the index finger of the left hand have commenced to pain him. He also has pain in the side of the face, involving the fifth nerve. I have examined his blood for the malarial parasite, and at night I have examined for the filaria, with negative results. I expect to make other examinations when I return home. The agglutination test should be made. I believe with these methods of diagnosis that the cases we have been treating for a long time as chronic malaria, chronic rheumatism, and chronic this or that, will some of them turn out to be Malta fever.

MAJOR CHARLES F. MASON, U. S. A., in closing, said: That the diag nosis of chronic rheumatism, or chronic malaria, is always a suspicious diagnosis to me, and I am never willing to take it, and if you investigate these cases, especially if you make repeated examinations of the blood and the excretions, you will find that chronic malaria will become very much less frequent in this country.

I also wish to say, in this connection, that the number of tropical diseases in this country is increasing, because the soldiers coming back from the Philippines bring them with them. Our troops that are now at home in San Antonio are much troubled with this Dhobie itch, which I believe is getting a strong hold here.


H. A. WEST, M. D.,


The word subjective, as applied to symptoms, is defined "as those symptoms experienced by the patient himself, and not amenable to physical exploration." For the purpose of this article I prefer to include in the list of subjective symptoms some of those that are objective also, as for example, dropsy, tachycardia, bradycardia, and symptoms relating to the renal secretion, which are both subjective and objective.

In these days when the importance of objective methods and laboratory diagnoses are considered of paramount importance there may be a tendency to minimize the significance of those symptoms which bring the patient to the doctor or compel him to send for the physician.

We should not forget in this connection the great diagnostic skill of our forefathers in medicine, who were enabled by the consideration alone of the subjective symptoms to make a diagnosis with a skill and rapidity which to us almost seems marvelous, when we call to mind that most of the methods of physical diagnosis were entirely unknown to them.

The intention of this article is to call renewed attention to the importance and significance of the subjective symptomatology relating to diseases of the heart. Like a lighthouse on a dangerous coast, or a guide-post at the crossing of the ways, these symptoms are the danger signals which indicate the seat of the disease in advance and direct the physician to various methods of physical examination.

In regard to the respective significance of the subjective and objective symptoms of heart disease, it is important to bear in mind that many symptoms indicative of heart trouble may occur entirely

disconnected with any disease of that organ, but an aggregation of symptoms showing a disturbed circulation is extremely suggestive, and in many cases a diagnosis of cardiac disease may be made entirely irrespective of physical signs. It is also important to bear in mind that such aggregation is not indicative of cardiac disease only, but is significant of ruptured compensation, of serious circulatory disturbance, of decreased arterial pressure, or transference of pressure from the arterial to the venous side of the circulation, hence conveying to us not only the knowledge that heart disease is present, but that the condition is a serious one, demanding careful therapeutic measures; whereas, on the contrary, we may have the presence of a very positive physical sign without any disturbance whatever of compensation, the patient himself having no intimation of any heart trouble, and where serious consequences may ensue if the knowledge is accidentally or of purpose conveyed to him. For example: If I was to ask what was the most important sign or symptom of heart disease the answer would probably be in nine cases out of ten "the existence of a cardiac murmur," while the truth of the matter is (we have the highest authority for this statement) that murmurs are really themselves of least diagnostic value: first, those of exocardiac may simulate those of endocardiac origin; second, because murmurs truly of valvular origin may disappear for the time being or permanently; third, we may have murmurs of valvular origin, but without permanent valvular lesion, which may disappear, leaving the heart uninjured; fourth, we may have murmurs of valvular origin, which may disappear temporarily, or even permanently, the lesion still continuing. Many serious forms of heart disease, productive of a long series of circulatory disturbances, are entirely disconnected from valvular disease, and hence unattended by murmurs; for example, various forms of myodegeneration, hypertrophy and dilatation due to a variety of causes.

It is obvious, therefore, that murmurs of themselves can not be accepted as certain indications of cardiac disease, even if we can positively connect them with lesion of definie origin, because that

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